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gPf CeG Y SAN JOA UIN Environmental Health Department —COUNTY �'�cgcra�`r Greatness grows here. SITE MITIGATION WELL & BORING PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 24 Hours Advance Notice Required For All Inspections CALL (209) 953-7697 For INSPECTIONS Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards. Job Address 306 North Ham Lane clty/state/zip Lodi, CA 95252 Phone Cross street West Lockeford Street APN 037-10-030 Property Owner' Stone Brothers & Associates (John Godi) Phone 209-200-8506 Address 1036 West Robinhood Drive, Suite 202 City/State/Zip Stockton, CA 95207 c-57 Contractor Environmental Control Associates (ECA)License# 695970 Phone 831-662-8178 Address 3011 Twin Palms Drive City/State/Zip -Aptos, CA 95003 Consultant/Sub-Contractor r f).Q{N License# Phon�,Y-�� p Address � �r A y/State/Zip C G T1 �n A r- I. .Y CONSTRUCTION WORK tTO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits h�'rQ`l-r0"O TYPE OFWELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 50'(2)& 15'(2) ❑BOLTED TRAFFIC BOX ❑STOVEPIPE ❑ EXTRACTION(Vapor/Water) 0 HAMMERIDRIVEN DM,OF BOREHOLE 2—I�❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA X SOILVAPORPROBE 4 0 MUD ROTARY CASING THICKNESS TYPE OF CASING: El STEEL ❑PVC ❑ OTHER [ SOIL BORING _ 4 X PUSH POINT(GP/CPT) CONDUCTORCASING ❑Yes ❑No Bodng Dia: Casin9 Dia: Casing Depth: ❑ INJECTION rAirsuaw.Ozaal 0 HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximu I pth b 30 FI) WEWSOIL BORING ID; B1 Bit GROUT SPECIFICATIONS Neat cement groutvi tremmie; Illsoil Vapor probe sand k CQfi 'do") pack/equipment will be r d before grouting DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPL1n #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_inches to depth of feet WELL IDS ❑PRESSUREGROUT To depth of feetbelowsurfaw GROUT SPECIFICATIONS [I EXPLOSIVES From to_feet below surface TREMIE TYPE TO BE USED El AUGERS [I HOSE [I PIPE ❑MUSHROOM CAP ❑3 feet below surface or feel below surface if>3 feet COMMENTS: I hereby certify that I am authorized to complete this application and that the work wlII be done in accordance with San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed Title/Company Project Manager/Partner Engineering & Science, Inc. Print Name Michel Helou Date 5/5/2023 D RTMENT USE ONLY LL r1 •� Application Accepted By: Date Issued: J / d 3 Grout Inspection By/Dates: 2 Destruction Inspection By/Dates: Z J tr GV N Facili /Site Information FA Name I ZpkQW o � FAAddress 30 A) , FA# 0 Z — PR# O��-g �� FA PE WP Reviewed By Work Plan Date 5 0C-57 7Authodzallon farOther to Sign Pool ❑Workers Comp ❑Workers Camp Waiver ❑Encroachment Permlt Agreement []Mad AgenCyA oval MF Comm r2 o d: n y}1A 7 �r .5 c 50r qoy- p/e P K1 A44 jy i e-4r2 excr o /�o'fC-' o rn.t,r r l t�N .-t - i� • »1 j-l- p o� � � It' fio �t-� �s' �Q ada Eji WP TYPE PE SC FEE INFO AMT REMITTED CHECK# D RECV' B D TE WELL PERMIT# INVOICE# Permfl Zq� 313 $156x G QO 1868 E. Hazelton Avenue i Stockton, California 95205 1 T 209' 4� 6�8�-3420 i F 209 464-0138 i www.sjcehd.com EHp 29-070420.23 CC - / 1 '4-CI '2— T T ` Site MlggaUon Well Penal Appllration